Company Ownership

Banking & Finance Reference

Bank Name*

Bank Address*

Street AddressStreet Address Line 2CityStateZip Code

Checking Account

Savings Account

Dun & Bradstreet

Single Choice*

I agree that, if I default on this agreement this company will forward my account to a collection agency for collection. I also understand I will be required to pay any and all collection expenses including, but not limited to, return check charges, collection fees, court costs, attorney fees, and highest interest allowed by law per annum in addition to the amount owed together with such damages as are permitted and prescribed by law.